Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: A

Rationale: Morning headaches that extend into the neck and subside as the day progresses can be indicative of elevated blood pressure, which is a common cause of morning headaches. Increased blood pressure can cause headaches that are usually worse in the morning due to the body's natural circadian rhythms. Monitoring the client's blood pressure and assessing for other signs of hypertension would be important in this case. Tachycardia, otitis media, and swollen lymph nodes are less likely to be associated with the described symptoms.

Correct Answer: C

Rationale: Bladder cancer is a health problem that can result from a combination of genetic and environmental factors. Genetic mutations can predispose individuals to developing bladder cancer, while environmental factors such as smoking, exposure to certain chemicals, and chronic bladder irritation can also contribute to the development of the disease. Hematuria (blood in the urine) can be a symptom of bladder cancer, but it is not specific to this type of cancer and can also occur in other renal system disorders. Incontinence and kidney infections are not typically associated with genetic predisposition as much as bladder cancer.

Correct Answer: B

Rationale: In eclampsia, seizures can occur due to the underlying hypertensive crisis affecting the brain. A classic grand mal seizure consists of two phases: the tonic phase and the clonic phase. During the tonic phase, there is a sudden loss of consciousness and muscle tone, leading to the person falling down. The clonic phase follows the tonic phase and is characterized by rhythmic, repetitive muscle contractions and relaxation. Therefore, the accurate statement about the characteristics of a grand mal seizure in the context of eclampsia is that the clonic phase is evidenced by muscular contraction and rigidity.

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.